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Evolution of resuscitation from the past to the present - evidence matters A history of CPR Dr. TSOI Ludwig Director, Resuscitation Council of Hong Kong President, Hong Kong Society for Emergency Medicine & Surgery Content An overview History of CPR Airway Ventilation Chest compression Defibrillation Modern CPR – why evidence matters What is Cardiac Arrest? Sudden loss of consciousness and breathing Cardiac output ceases Coronary and cerebral blood flows stop Expected Effect of CPR CPR has potential of re-establishing spontaneous circulation, often in conjunction with electrical defibrillation But CPR is likely to be successful only if it is instituted early Chain of Survival AHA (1991) introduced concept ‘‘chain of survival’’ Addressing This chain includes four links: Utstein template Template for documenting the sequence of interventions Begin with call for emergency assistance, documents arrival time of rescuers (including by-standers), interventions performed by emergency medical responders at site, and sequences of interventions that follow Figure 1. Overview of EMS-treated cardiac arrests with an abridged Utstein template (May 1, 1998, to December 31, 2006). Taku Iwami et al. Circulation. 2009;119:728-734 Copyright © American Heart Association, Inc. All rights reserved. Automated External Defibrillator (AED) In ventricular fibrillation (VF), automated external defibrillators (AEDs) have empowered nonprofessionals to reverse VF Current evidence supports value of bystander-initiated CPR program and Public Access Defibrillation (PAD) History of CPR Until the nineteenth century, routine resuscitation from death was not viewed as feasible Modern cardiopulmonary resuscitation emerged only during latter half of twentieth century 1934 Causes of cardiac arrest 1. In the 1900s, asphyxia was a major cause of cardiac arrest Airway devices and mechanical interventions 2. Electrical causes became significant causes of cardiac arrest Prompted the development and use of defibrillation External mechanical methods for restoring blood circulation were a development of 1960s Sequence of interventions was established under the acronym ABCD History of airway intervention Ancient Babylonian (200BC – 400AD) lamb Reed This anticipated the modern method of securing the airway followed by mechanical ventilation Air Pipe First endotracheal tube Endotracheal tube airway Tongue be withdrawn and displaced to extreme right corner of the mouth 1870 Friedrich Trendelenburg (1844 - 1924) popularized “tube” Howard B. The direct method of artificial respiration. Lancet 1877;2:193–6 Laryngoscope Kirstein A. Autoskopie des larynx und der trachea. Archiv Laryngologie Rhinologie 1895;3:156–64 [German] Alfred Kirstein (1863 – 1922) OPA Peter Safar (1924 – 2003) Head tilt-chin lift Ancient Egyptian Mythology Isis Hebrew Bible Elisha Mouth-to-nose method 200 BC – 500 AD: Hebrews used mouth-to-nose ventilation for resuscitation of newborn infants Primitive fireplace bellows - Galen (175 AD) first described bellows-to-nostril ventilation in human Mouth-tomouth “I applied my Mouth close to his…, I blew again my Breath as strong as I could…his Thorax continued to play…” Dr. William Tossach (1732) Exhaled air “devitalized” air vs. Oxygen Drowning Drowning 1857 Marshall Hall – “chest-pressure” 1861 Silvester – “chest-compression arm-lift” – various modifications Tank respirator Drinker respirator or “iron lung” Intermittent positive pressure ventilation (IPPV) 1952 Bjørn Ibsen (Denmark) Mouth-to-mask ventilation 1954 Dr. Elam J. O. 1950s Endotracheal tube Bennet Compact ventilator 1958 Ruben “self-refilling bag” Engstrom Ancient Hebrews Bible I King Chapter 17 Elijah “Then he stretched himself upon the child three times…” Barrel and Horse methods Direct cardiac compressions Moritz Schiff described in 1874 Precordium compression 1878 Rudolph Boehm and Louis Mickwitz – cats 1883 Koening – chloroform patient 1891 Friedrich Maass – successful Open-chest cardiac massage 1901 Kristian Igelsrud (1867 - 1940) Rediscover chest compression 1958 William Kouwenhoven: all survived to discharge External chest compression + assisted ventilation Ventricular fibrillation (VF) 1889 John McWilliam – VF cause of cardiac arrest Defibrillation 1899 Prevost and Battelli – 1st defibrillation Energy level 1933 Hooker et al - dogs Milestones of defibrillation 1940 Carl Wiggers – dog 1947 Claude Beck – boy (openchest defib) 1955 Paul Zoll – man (closedchest defib) 1962 Bernard Lown – direct current monophasic waveform defibrillation 1979 1st portable external defibrillator Modern era of CPR Since 1960* Mini-thoracotomy discard in favor of closed-chest compressions Electrical defibrillation Layperson CPR Manikin for CPR training Utstein Template *Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. J Am Med Assoc 1960;173:1064–7. Evidence matters 1966 AHA – 1st National Conference on Standards for CPR and Emergency Cardiac Care Rapid response systems evolved HK: ~5000 OHCA (internal communication) Survival rate: still low Lack of by-stander CPR – the weakest link What is evidence? Evidence = Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients ≠ randomized controlled studies (RCT) or systemic review of RCT When RCT or systemic review lacking EBM Pyramid AHA and International Liaison Committee on Resuscitation (ILCOR) – review and publish guidelines with emerging evidence every 5 years 2005 Uninterrupted precordial compression 2010 Change from ABC to CAB 2015 Check pulse and breathing at the same time Grading of evidence into practice Local consideration Airway Prehospital LMA (? ET tube) Breathing Compression only CPR Circulation Mechanical chest compression (Lucas 2) EMCO-CPR Reference Ristagno G, Tang W, Weil MH. Cardiopulmonary Resuscitation: From the Beginning to the Present Day. Crit Care Clin 25 (2009) 133–151 Nakagawa Y, Weil MH, Tang W. The history of CPR. In: Weil MH, Tang W, editors. CPR. Resuscitation of the Arrested Heart. Philadelphia: WB Saunders; 1999. p. 1–12. Harrison-Paul R. A history of mechanical devices for providing external chest compressions. Resuscitation 2007;73(3):330–6. Thank you